Registered Nurse (RN) Care Coordinator

Riverside Health; Newport News (VA); On-site; USD 53,000 - 73,000; Full time

Job summary

Riverside Health in Newport News, Virginia, seeks a skilled RN for discharge planning and case management. You will lead the discharge process, assess clinical and psychosocial needs, and coordinate smooth transitions to home or other care settings to optimize outcomes.

The role requires 3–4 years of nursing experience, an active Virginia RN license, and collaboration with an interdisciplinary team to ensure regulatory compliance and patient-centered care.

Qualifications

• RN license required in Virginia (VDHP)
• 3–4 years clinical experience required
• 1 year case management preferred

Responsibilities

• Lead discharge planning from admission through post-discharge follow-up.
• Conduct comprehensive assessments of patients' clinical and psychosocial needs.
• Develop, implement, and update individualized discharge plans.
• Coordinate safe transitions to home, SNF, rehab, or behavioral health.

Skills

Discharge planning

Care coordination

Interdisciplinary collaboration

Patient education

Education

Diploma in Nursing

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Job description

Newport News, Virginia – Hiring Range $38.60 - $53.08/Hourly. Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs.

Overview

Works under the supervision of the department leadership and is responsible for working in collaboration with the healthcare team to coordinate the care and service to patients across the continuum of care, promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical and resource outcomes. Works to provide a comprehensive range of services or clinical care associated with and in accordance with standards of excellence established by Riverside Health system and facility goals and strategic plans. Utilizes national hospital based ACMA Scope of Services and Standards of Practice as foundation of Care Management.

What you will do

• Lead discharge planning from admission through post-discharge follow-up.
• Conduct comprehensive assessments of patients’ clinical, psychosocial, and discharge planning needs.
• Develop, implement, and update individualized and cost-effective discharge plans.
• Utilizes sequencing of interventions for safe, timely, efficient, effective, equitable, and patient-centered transitional planning.
• Coordinate safe and timely transitions to appropriate levels of care including but not limited to home, skilled nursing facility, acute rehab, and behavioral health.
• Collaborate with the interdisciplinary team, patient, their family/support system, payers, and community resources to ensure a smooth transition of care.
• Act as a liaison between the clinical team, patient and family, and any external agencies in the development of safe discharge plans.
• Participate in daily rounds, case conference, family meetings, weekly outlier case reviews, and multidisciplinary team meetings, communicating discharge updates clearly and proactively to all stakeholders.
• Ensure compliance with federal and state discharge planning regulations, in accordance with CMS’ Conditions of Participation.
• Monitor length of stay and identify/resolve barriers to timely discharge.
• Promote transparency and open communication by maintaining accurate, timely, and compliant documentation in the medical record.
• Maintain current knowledge of care management best practices and regulatory changes and understand Medicare/Medicaid, managed care, and other payer requirements.
• Delivers all notices (i.e. Important Message from Medicare, Medicare Outpatient Observation Notice) appropriately and according to CMS regulatory guidelines.
• Promote patient-centered care and shared decision-making in the development of appropriate discharge plans.
• Educate patients and families on treatment plans, discharge options, and available resources.
• Places referrals to complex case management as needed.
• Participate in quality improvement initiatives related to readmissions, throughput, and patient outcomes.
• Identify and document internal and external avoidable days.
• Act as a resource to fellow non-clinical care coordinators and assist with appropriate discharge planning as necessary.

Qualifications

• Education: Program Graduate, Nursing - Diploma Program (Required) or Associates Degree, Nursing (Required) or Bachelors Degree, Nursing (Preferred)
• Experience: 3-4 years Clinical experience required (may include LPN experience) (Required) 1 year Case management experience (Preferred)
• Licenses and Certifications: Registered Nurse (RN) – Virginia Department of Health Professions (VDHP) Upon Hire(Required) Accredited Case Manager (ACM) – American Case Management Association (ACMA)/CCM Upon Hire (Preferred)

To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers. If loving your work is important to you, consider a career at Riverside. By joining our team, you can make a difference in people's lives. Our mission is to care for others as we would care for those we love. We extend that sense of caring to every patient, resident and customer, as well as to each member of our team. We offer care at all stages of life, in hundreds of locations, giving you room to grow your career, along with great benefits and perks. At Riverside Health, your trust and safety are our top priorities.

Unfortunately, job scams are on the rise across the country, and we want to help you feel confident in knowing what is — and is not — part of our hiring process. Learn more about how to recognize a legitimate Riverside job opportunity and what to do if you suspect a scam by visiting this site.